Cognitive Therapy for Command Hallucinations

An advanced practical companion

Alan Meaden, Nadine Keen, Robert Aston, Karen Barton, Sandra Bucci

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780415625289
• eBook ISBN: 9781136200946
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Auditory hallucinations rank amongst the most treatment resistant symptoms of schizophrenia, with command hallucinations being the most distressing, high risk and treatment resistant of all.

This new work provides clinicians with a detailed guide, illustrating in depth the techniques and strategies developed for working with command hallucinations. Woven throughout with key cases and clinical examples, Cognitive Therapy for Command Hallucinations clearly demonstrates how these techniques can be applied in a clinical setting. Strategies and solutions for overcoming therapeutic obstacles are shown alongside treatment successes and failures to provide the reader with an accurate understanding of the complexities of cognitive therapy.

This helpful and practical guide with be of interest to clinical and forensic psychologists, cognitive behavioural therapists, nurses and psychiatrists.

Chapter 1

CTCH Level 1

Assessment and Engagement

Introduction

The aim of a good assessment process is as much about determining how to offer help as it is about what help can be offered. As a trial-based therapy, CTCH inevitably has a large number of assessment measures which may pose problems for adoption into routine clinical practice given often limited resources and time constraints. In this chapter we are mindful of these considerations in writing a text for clinicians. We describe the measures we have used as well as the general principles and steps of assessment in CTCH. Level 1 work is also about engaging the individual in the process of therapy. Good engagement is the central vehicle for the delivery of other interventions in CTCH and encompasses the concept of therapeutic alliance (Gillespie and Meaden, 2009), a crucial factor in achieving good outcomes. The first and fourth authors have conducted a small exploratory study in the context of ongoing trial work examining the role of engagement in CTCH. While engagement is widely acknowledged as a good predictor of outcome in psychotherapy (Horvath and Symonds, 1991; Martin et al., 2000), it has very rarely been measured in randomised controlled trials of CBTp. This is surprising given that people who experience psychosis can be difficult to engage in mental health services (Sainsbury Centre for Mental Health, 1998). Utilising the Hall et al. (2001) scale we rated engagement at monthly intervals for a subset of therapy dyads (n = 36). Initial results suggest that engagement with CTCH from the outset was often very high, indicating that the participants found the approach relevant to their needs. Initial analysis further suggests that engagement scores at session 1 were predictive of subsequent engagement, while those who disengaged from CTCH early were very poorly engaged from the beginning. In isolated cases, however, therapist’s were able to extend the engagement period and improve engagement overall. Consequently, the Hall et al. (2001) measure may prove useful in identifying those most likely to remain engaged in CTCH as well as those clients needing additional emphasis on level 1 work. The key tasks in this level are to:

1. undertake a detailed assessment of the broad experience and impact of command hallucinations;
2. obtain a detailed ABC assessment of the content of the client’s voices, which beliefs these give rise to, and their emotional and behavioural consequences, leaving to later stages (levels 7 and 8) the client’s beliefs about themselves and others (noting these if they emerge and where relevant);
3. anticipate and address problems with engagement;
4. convey empathy and acceptance and build trust;
5. set initial therapy goals focused on reducing distress and harmful behaviours.

We illustrate these processes in this chapter with reference to our two main case studies Peter and Angel.

Assessment

In order to assess suitability for CTCH, we recommend using a range of measures to assess the defining features of the client’s beliefs about their voices, their degree of resistance and engagement with their voices as well as the level of distress and compliance behaviours mediated by their beliefs. In line with forming a strong therapeutic alliance, care must be taken when administering assessment measures in the early stage of therapy. Some clients might find it disconcerting if their initial contact with the therapist is focused on answering a barrage of questions, with little time for them to tell their story in their own time and in their own way. Other clients will respond well to the structure of assessment measures as the pressure is taken off them to tell their story at the outset. This may be the case particularly for those clients who are anxious or even ambivalent about therapy. The therapist will therefore need to tailor their assessment approach to best engage the client. Below is a list of those measures we recommend therapists use as key measures:

1. The Beliefs about Voices Questionnaire-Revised (BAVQ-R, Chadwick et al., 2000) was developed initially as a cognitive assessment of voices to examine the mediating role of voice beliefs in distress and behaviour. The revised questionnaire now includes ratings of Disagree, Unsure, Slightly Agree and Strongly Agree to rate key beliefs about auditory hallucinations, including benevolence, malevolence and two dimensions of relationship with the voice: ‘engagement’ and ‘resistance’. Like its companion assessment, the cognitive assessment of voices interview schedule, it is usually completed on the most dominant and distressing voice.
2. The cognitive assessment of voices (CAV; Chadwick and Birchwood, 1994) further assesses the individual’s feelings and behaviour in relation to the voice, and their beliefs about the voice’s identity, power, purpose or meaning, and in the case of command hallucinations, the most likely consequences of obedience or resistance.
3. The Voice Compliance Scale (VCS; Beck-Sander et al., 1997) is an observer-rated scale designed to specifically measure the frequency of command hallucinations and level of compliance/resistance with each identified command within the previous 8 weeks.
4. The Voice Power Differential Scale (VPDS; Birchwood et al., 2000a) measures the perceived relative power differential between the voice (usually the most dominant voice) and the voice hearer, with regard to the components of power including strength, confidence, respect, ability to inflict harm, superiority and knowledge. Each is rated on a five-point scale and yields a total power score.
5. The Psychotic Symptom Rating Scales (PSYRATS; Haddock et al., 1999) measures the severity of and distress associated with a number of dimensions of auditory hallucinations and delusions.

Additional useful measures which we have developed with colleagues over recent years or have drawn upon in our research work with them are the following:

1. The Omniscience Scale (OS; Birchwood et al., 2000a) measures the voice hearer’s beliefs about their voices’ knowledge regarding personal information.
2. The Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987) is a widely used, well established and a comprehensive symptom rating scale measuring mental state.
3. The Calgary Depression Scale for Schizophrenia (CDSS; Addington et al., 1993) is specifically designed for assessing the level of depression in people with a diagnosis of schizophrenia.
4. The Risk of Acting on Commands Scale (RACS; Byrne et al., 2006) was specifically designed to identify the level of risk of acting on commands and the amount of distress associated with them.

By utilising these measures the assessment process should enable clinicians to identify suitable clients for CTCH. Although not confined to these criteria, we have found that CTCH is most useful for clients who meet the following conditions:

1. an ICD-10 diagnosis of schizophrenia, schizoaffective or delusional disorder under the care of the clinical team (F20, 22, 23, 25, 28, 29);
2. command hallucinations (PANSS P3 hallucinations score ≥3) with a history of command hallucinations lasting at least 6 months with harmful compliance (Voice Compliance Scale score ≥3), including appeasement, harm to self and others or major social transgressions;
3. collateral evidence of ‘harmful’ compliance behaviour linked to command hallucinations (e.g. reported by other professionals or evident from case notes);
4. distress associated with compliance or resistance;
5. be ‘treatment resistant’ (prescribed at least two neuroleptics without response but on a stable dose of medication for a period of 3 months) or ‘treatment reluctant’ (refusal to accept optimal medication (e.g. clozapine);
6. not have organic impairment or addictive disorder considered to be the primary diagnosis.

Clinicians working in busy routine settings, however, do not always have the capacity to spend two, three or more sessions administering such a compre -hensive assessment battery. Nevertheless, we do advocate spending one to two sessions administering the five key measures listed above. In our practice we have found that this can facilitate the engagement process, help identify particular areas that might be more important to focus upon than others and capture change post-therapy, providing evidence of the changes that have been made.

The skilled therapist must strive to strike the balance between asking the questions necessary to arrive at ratings on these measures while allowing the client to tell their story and feel heard and understood. The focus of assessment in CTCH is (at least initially) upon the most dominant voice since this will usually be the one appraised as being most powerful and therefore the one most clearly associated with mediating distress and harmful compliance.

General assessment principles will also apply at this stage and may involve reviewing the client’s personal and psychiatric history, interventions received so far and the client’s response to them, as well as general stressors, triggers and maintenance factors. The assessment process must also take into account other individual factors (Meaden, 2009) including:

• the current stage of psychosis (e.g. stability, relapse or residual difficulties);
• any attention and concentration problems, requiring shorter sessions;
• social withdrawal or negative symptoms, requiring a slower pace and greater time to reply [Such clients may benefit from a more supportive or gentle conversational style (Kingdon and Turkington, 2005).];
• suggestibility, requiring the use of open questions;
• high levels of suspiciousness and mistrust, suggesting particular attention to therapeutic alliance issues;
• sensory impairment, requiring specialist advice.

Eliciting the As, Bs and Cs

The above measures and assessment processes are designed to cover most aspects of the client’s experience of hearing voices. The BAVQ-R and CAV also elicit the general ABC of the client’s voice hearing experience. However, this general cognitive assessment does not readily help to clarify which As lead to which Bs and which Cs. This is essential for formulation, goal planning and intervention. The therapist may usefully focus upon a single recent and distressing incident involving the use of a safety behaviour. Such recent events can be recalled and analysed since they will have greater emotional salience. The CAB (Consequences, Activating event and Beliefs) process described by Meaden and Hacker (2010) and summarised below is a useful framework:

1. Ask about the behaviour (obtain the Cb) – if the behavioural consequence is not clear clarify it (this is the safety behaviour in CTCH terms).
2. Ask about the emotional consequence (obtain the Ce) – if the emotional consequence is not clear clarify it.
3. Enquire about the actual A which led to the interpretation or belief.
4. Establish the A–B link: ‘So the voice said you are on your way and you took that to mean you were about to be killed?’ – eliciting and clarifying the B.
5. Reflect back the information gleaned from the CAB process as an A–B–C chain: ‘So the voice said you are on your way (A) and you took that to mean you were about to be killed (B) and understandably you felt very afraid (Ce) and locked yourself in the bedroom’ (Cb; a threat mitigation strategy in safety behaviour terms?) This also serves to socialise the client into the model.

Case Example: Tony

Tony assaulted his mother (the Cb) – he shouted at her and punched her on the arm.

Tony was distressed (the Ce) – he felt afraid.

Tony heard his voice say ‘Kill your mother’ (A).

Tony believed that he should act but not fully comply (B; his compliance beliefs) – ‘I must do what my voice says otherwise they will kill her’ and ‘Hitting her will keep them quiet’.

Other ABCs can then be clarified, which may lead to different types of distress and behaviour rather than harmful compliance: derogatory insults (A) – ‘you’re a fool’ which Tony believes to be true (B) – ‘I am a prat’ and is distressed about (Ce) – feels low, and may act upon (Cb) – Tony withdraws and stays in bed.

This level of assessment enables the therapist and client to agree which behaviours and distress, and which beliefs, should be the focus of further assessment (e.g. eliciting the evidence for), goal setting and intervention. It also enables the clinician to be clear about whether the harmful behaviour is voice driven: is it harmful compliance or does it serve some other function and therefore require a different type of intervention?

Case Example: Ali

Ali hears a persistent voice saying you are worthless and ugly (A). After several hours of abuse from the voices she cuts herself (Cb) as a means of easing the distress that this experience causes her (Ce) but not because of any compliance belief but rather because she believes that this is an effective way of managing her distress (B) since it functions to focus her attention away from her voices and also elicits care from others.

Cognitive work may be aimed at addressing discomfort intolerance beliefs rather than any compliance beliefs she may otherwise hold. Intervention for Ali may further usefully focus upon improving her emotional regulation and self-soothing skills.

Some clients find it difficult to accurately recall incidents of voice activity. Allocating time to log such activity is a helpful strategy in assessment. Using this technique, the therapist gives the client a blank notepad, or a ‘voice diary’ (see Appendix 4 for an example) and invites the client to log the content of the voices as well as the client’s own thoughts, beliefs, fears, etc. in response to their voice activity. Provided the client is in agreement, both therapist and client can then review the diary in session. In this way, the therapist is not reliant on the client’s memory of voice activity and may even elicit a much richer exploration of the content of the voice.

Angel’s Assessment

Information obtained from Angel’s general assessment is summarised in the preceding introduction and overview. Here, we report the detailed assessment findings regarding Angel’s voices derived from our assessment tools described above.

Angel reported hearing two voices: a male and a female voice, both of whom were equally dominant. As well as criticising Angel, for example by saying ‘you’re useless’, ‘you’re a fraud’, the voices instructed her to do a number of things that she did not want to do. These commands ranged from somewhat innocuous commands such as ‘leave the room’ and ‘stand up’ to more risky commands such as ‘don’t take your medication’, ‘walk in the road (in front of cars)’ and ‘go to the park to sacrifice yourself (set yourself alight)’. Angel reported hearing the voices almost continuously, often lasting for hours at a time. She said that they sounded like they originated from outside of her head and that they spoke more loudly than she did. She described their content as always unpleasant and negative; understandably Angel found the voices very distressing. In terms of Angel’s mood, she presented as very low and rated in the severe range for depression on the CDSS. Furthermore, Angel described feeling anxious, guilty and bad ‘all of the time’.

Angel’s Beliefs about her Voices

Angel believed with 100 per cent conviction that the voices were messengers from God which she felt compelled to listen to because she believed that they were teaching her ‘the right way’. She was concerned that if she did not listen, she would miss out on ‘warnings’ of bad things that might happen. Furthermore, Angel believed that if she did not comply with what the voices commanded, bad things would happen to other people. Consequently, Angel generally complied at least partially with their commands. This led to Angel putting herself in a number of very risky situations, such as going to the park with lighter fluid with the intention of sacrificing herself. On one occasion she tried to set fire to herself but a passerby intervened. Angel also walked out into the road in front of cars on several occasions. When she did this, sometimes oncomi...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• List of appendices
• List of figures
• List of tables
• Notes on the cover art
• Preface
• Acknowledgements
• List of abbreviations
• Introduction and overview
• 1. CTCH Level 1: Assessment and engagement
• 2. CTCH Level 2: Promoting control
• 3. CTCH Level 3: Socialising the client into the cognitive model and developing the formulation
• 4. CTCH Level 4: Reframing and disputing power, omniscience and compliance beliefs
• 5. CTCH Level 5: Reducing safety behaviours and compliance
• 6. CTCH Level 6: Raising the power of the individual
• 7. CTCH Level 7: Addressing beliefs about voice identity, meaning and purpose
• 8. CTCH Level 8: Addressing the psychological origins of command hallucinations: working with core schemas
• 9. Ending therapy and promoting longer term change
• 10. Special issues
• 11. Future directions in CTCH
• Appendices
• References
• Index